NCLEX-RN Comprehensive Practice
Exam 004 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A nurse is caring for a client with heart failure who reports increasing
shortness of breath. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, a
life-threatening complication of heart failure. The client requires immediate
assessment and intervention to improve oxygenation and reduce pulmonary
congestion.
2. A client is prescribed digoxin. Which finding should cause the nurse to
withhold the medication and notify the provider?
A. Apical pulse of 54/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. In adults, the medication is
generally withheld when the apical pulse is below 60/min, and the provider
should be notified.
, 3. A nurse is teaching a client who takes warfarin. Which statement
indicates correct understanding?
A. “I should avoid all foods containing vitamin K.”
B. “I can double my dose if I miss one.”
C. “I should keep my vitamin K intake consistent.”
D. “I do not need blood tests while taking this medication.”
Answer: I should keep my vitamin K intake consistent.
Rationale: Vitamin K affects warfarin effectiveness. Clients should maintain a
consistent intake rather than completely avoiding vitamin K-containing foods.
INR monitoring is also essential.
4. A client with diabetes mellitus is diaphoretic, trembling, and confused.
What is the nurse's priority action?
A. Administer regular insulin
B. Check the client's urine ketones
C. Give a rapid-acting source of glucose
D. Encourage the client to ambulate
Answer: Give a rapid-acting source of glucose
Rationale: Diaphoresis, tremors, and confusion are manifestations of
hypoglycemia. If the client is conscious and able to swallow, rapid-acting
glucose should be given immediately.
5. Which finding is most concerning in a client with increased intracranial
pressure?
A. Headache
B. Projectile vomiting
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening intracranial pressure and possible cerebral
deterioration.
, 6. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen at 4 L/min by nasal cannula
C. Pulse oximetry monitoring
D. Positioning in semi-Fowler's position
Answer: Oxygen at 4 L/min by nasal cannula
Rationale: Clients with COPD may have chronic carbon dioxide retention and
require carefully titrated oxygen. Excessive oxygen administration can worsen
ventilation in susceptible clients.
7. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Reassure the client
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and
normal saline should be administered through new tubing according to
protocol.
8. A nurse is caring for a client with potassium level of 2.8 mEq/L. Which
finding should the nurse anticipate?
A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: Muscle weakness
, Rationale: Hypokalemia commonly causes muscle weakness, fatigue,
constipation, and cardiac dysrhythmias. Peaked T waves are associated with
hyperkalemia.
9. A client with suspected bacterial meningitis is admitted. Which isolation
precaution is appropriate initially?
A. Airborne
B. Contact
C. Droplet
D. Protective
Answer: Droplet
Rationale: Bacterial meningitis caused by organisms such as Neisseria
meningitidis requires droplet precautions until the client has received
appropriate antibiotic therapy for the recommended period.
10.Which assessment finding is expected in a client experiencing
hypovolemic shock?
A. Bounding pulse
B. Warm, flushed skin
C. Tachycardia
D. Bradycardia
Answer: Tachycardia
Rationale: The body compensates for decreased circulating volume by
increasing heart rate and systemic vascular resistance. Tachycardia is an early
finding in hypovolemic shock.
11.A nurse is assessing a client with Addison disease. Which finding is
expected?
A. Hypertension
B. Hypernatremia
C. Hyperpigmentation
D. Hypoglycemia is absent
Answer: Hyperpigmentation
Exam 004 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client with heart failure who reports increasing
shortness of breath. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, a
life-threatening complication of heart failure. The client requires immediate
assessment and intervention to improve oxygenation and reduce pulmonary
congestion.
2. A client is prescribed digoxin. Which finding should cause the nurse to
withhold the medication and notify the provider?
A. Apical pulse of 54/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. In adults, the medication is
generally withheld when the apical pulse is below 60/min, and the provider
should be notified.
, 3. A nurse is teaching a client who takes warfarin. Which statement
indicates correct understanding?
A. “I should avoid all foods containing vitamin K.”
B. “I can double my dose if I miss one.”
C. “I should keep my vitamin K intake consistent.”
D. “I do not need blood tests while taking this medication.”
Answer: I should keep my vitamin K intake consistent.
Rationale: Vitamin K affects warfarin effectiveness. Clients should maintain a
consistent intake rather than completely avoiding vitamin K-containing foods.
INR monitoring is also essential.
4. A client with diabetes mellitus is diaphoretic, trembling, and confused.
What is the nurse's priority action?
A. Administer regular insulin
B. Check the client's urine ketones
C. Give a rapid-acting source of glucose
D. Encourage the client to ambulate
Answer: Give a rapid-acting source of glucose
Rationale: Diaphoresis, tremors, and confusion are manifestations of
hypoglycemia. If the client is conscious and able to swallow, rapid-acting
glucose should be given immediately.
5. Which finding is most concerning in a client with increased intracranial
pressure?
A. Headache
B. Projectile vomiting
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening intracranial pressure and possible cerebral
deterioration.
, 6. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen at 4 L/min by nasal cannula
C. Pulse oximetry monitoring
D. Positioning in semi-Fowler's position
Answer: Oxygen at 4 L/min by nasal cannula
Rationale: Clients with COPD may have chronic carbon dioxide retention and
require carefully titrated oxygen. Excessive oxygen administration can worsen
ventilation in susceptible clients.
7. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Reassure the client
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and
normal saline should be administered through new tubing according to
protocol.
8. A nurse is caring for a client with potassium level of 2.8 mEq/L. Which
finding should the nurse anticipate?
A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: Muscle weakness
, Rationale: Hypokalemia commonly causes muscle weakness, fatigue,
constipation, and cardiac dysrhythmias. Peaked T waves are associated with
hyperkalemia.
9. A client with suspected bacterial meningitis is admitted. Which isolation
precaution is appropriate initially?
A. Airborne
B. Contact
C. Droplet
D. Protective
Answer: Droplet
Rationale: Bacterial meningitis caused by organisms such as Neisseria
meningitidis requires droplet precautions until the client has received
appropriate antibiotic therapy for the recommended period.
10.Which assessment finding is expected in a client experiencing
hypovolemic shock?
A. Bounding pulse
B. Warm, flushed skin
C. Tachycardia
D. Bradycardia
Answer: Tachycardia
Rationale: The body compensates for decreased circulating volume by
increasing heart rate and systemic vascular resistance. Tachycardia is an early
finding in hypovolemic shock.
11.A nurse is assessing a client with Addison disease. Which finding is
expected?
A. Hypertension
B. Hypernatremia
C. Hyperpigmentation
D. Hypoglycemia is absent
Answer: Hyperpigmentation
